Health plans - fraud

California Faces Major Reversal If Trump, Congress Scrap Health Law"The Golden State fully embraced the [ACA] by expanding Medicaid coverage for the poor and creating its own health insurance exchange for about 1.4 million enrollees. Supporters held California up as proof the health law could work as intended.... The number of uninsured Californians would more than double to 7.5 million people if the [ACA] was repealed[.]" (Kaiser Health News)

2015 Group Health Plan Checklist"With 2015 just around the corner, certain mandates under the [ACA] are about to become effective. Health plans also have several existing enrollment and annual notice requirements. [This article] is a checklist of upcoming ACA mandates that employers must implement in preparation for or in 2015 and a summary of existing enrollment and annual notice requirements." (Benefits Bryan Cave)

Will You Buy Your Health Insurance at Walmart?"Since World War II, when employer-sponsored health insurance became the principal way Americans access insurance, health care has been business-to-business. Employers choose health insurers, and increasingly insurers choose providers, who choose specialist providers. And that's accepted because the employer pays the bill, or used to. Consumers did not know, or need to know, much about purchasing health care. The system told them what to do. This is now changing fast[.]" (Forbes)

HHS OIG Report Finds More Flaws in Digitizing Patient Files"Despite spending 'considerable resources to promote widespread adoption of [electronic health records (EHRs)], the government has 'directed less attention to addressing potential fraud and abuse,' according to the report.... While the report did not estimate the amount of fraud that may be occurring, earlier government estimates have said it could run in the hundreds of millions of dollars. Although the amount is a fraction of the trillions of dollars spent annually on health care, the lack of safeguards at a time when the new technology is becoming pervasive could allow the fraud to balloon." (The New York Times; subscription may be required)

Using Obamacare as Bait, Scam Artists Target Consumers and Business Owners"Most of the schemes target uninsured individuals and employers, many of whom will soon be required to purchase a minimum level of health coverage or pay a tax penalty. In some cases, scammers have set up bogus Web sites intended to look like the law's new health insurance exchanges, where individuals and small business owners will be allowed to shop for coverage starting on Oct. 1." (The Washington Post; subscription may be required)

[Opinion] It's Fact, Not Anecdote, That Obamacare Is Turning Us Into a Part-Time Nation"Bureau of Labor Statistics data show that the ratio of part-time to full-time jobs has completely flipped this year from historical trends. Last year, six full-time jobs were created for every one part time job. This year, only one full-time job is being created for every four new part-time jobs. The shift to part-time has accelerated over the past several months because of the 'look back' provision in ObamaCare that sets the baseline this year for the number of full-time workers a company employs to determine their compliance with the employer pay-or-play mandate." (Galen Institute)

Advocacy Group Says ACA Requires Federally-Funded Employers to Provide Pregnancy Coverage for Dependents"The complaints appear to be among the first instances in which a group is using specific provisions of the federal health-care law to challenge the design of an insurance policy. The complaints are rooted in a health-law provision requiring employers to allow workers to keep dependents up to 26 years old on their coverage plans.... [T]he National Women's Law Center contends that excluding maternity coverage for employees' daughters violates a provision of the law barring sex discrimination in health-care programs that receive federal funds." (The Wall Street Journal; subscription may be required)

DOL Asserts New Power to Seize Assets of Fraudulent Health Care Pools"The Labor Department has prosecuted abuse of the insurance pools in the past, but the new rule would cut through the red tape associated with freezing assets and issuing a 'cease and desist order' to a deceptive insurance promoter. The rules allow the secretary of Labor to assess from a fraudulent program if there is 'probable cause' that the plan is in a 'financially hazardous condition'." (The Hill)

Health Care CEO Charged With Failure to Pay Premiums"The North Carolina Department of Insurance issued the following news release: Insurance Commissioner Wayne Goodwin today announced the arrest of Rebecca Horne Wood, 36, of ... Rocky Mount; she is charged with one count each of failing to pay premiums deducted from employee pay and failing to notify employees of insurance cancellation [while acting as CEO and president of Alpha/Omega Health Care in Raleigh]." (InsuranceNewsNet.com)

Government Employees in Missouri Indicted for Defrauding Employer-Sponsored Wellness Program"According to an indictment filed in the U.S. District Court for the Western District of Missouri, within the first six months of the existence of the Points to Blue wellness program in 2010, member employees of Jackson County and Kansas City, Missouri, began falsifying activity entries ... by falsely claiming to have completed the most strenuous activities in order to obtain the maximum value gift card or preloaded debit card in the amount of $250.... The employees altogether received 1,253 gift cards totaling $310,960. Each employee faces a maximum of 60 years in prison and a $750,000 fine if convicted on all counts" (PLANSPONSOR.com)

Reducing Wasteful Spending on Health Care"[T]he United States spent nearly $650 billion more than did other developed countries in 2006, and that this difference was not due to the U.S. population being sicker. This spending was fueled by factors such as growth in provider capacity for outpatient services, technological innovation, and growth in demand in response to greater availability of those services. Another $91 billion in wasteful costs or 14 percent of the total was due to inefficient and redundant health administration practices." (Health Affairs)

[Opinion] Fourth Circuit Limits Scope of ERISA Anti-Retaliation Statute"While ERISA protects employees who report wrongdoings by their employers across most of the country, folks in the 2nd, 3rd and 4th federal court circuits are not protected when they report issues 'internally' -- that means to their employers. Folks in all the other federal circuits are protected.... [T]he only way to now fix the problem is to amend ERISA so that it clearly protects people who file what are called 'internal reports'; that is, when a person files a report or sends an email to his or her supervisor or executive management that says, 'Hey, I think we have a problem here'." (Winston-Salem Journal)

Deloitte's 2012 U.S. Survey of Health Care ConsumersClick on the Download button on the linked web page. "Since 2008, the Deloitte Center for Health Solutions has annually polled up to 4,000 U.S. adult consumers about their interest in and ability to operate in a consumer health care market. These surveys queried adults in various age, health status, income, and insurance cohorts to gauge the degree to which consumers are prepared to engage with the health care system as 'patients' or 'consumers.' The distinctions between the two are stark; the implications are transformative -- not only to the health care industry, but to every U.S. household, company, and government agency." (Deloitte Center for Health Solutions)

[Opinion] New MEWA Reporting Requirements: An Unlikely Solution to MEWA Fraud"The DOL has proposed a rule that, upon adoption, would implement reporting requirements for MEWAs and certain other entities that offer or provide health benefits for employees of two or more employers.... The DOL seems to think that the new requirements, penalties and criminal sanctions for false reports will have an effect on promotion of fraudulent MEWA's. Why?" (Health Plan Law)

Focus on Health Care Fraud: MEWAsThis Web page is a collection of information starting with the fact sheet: 'How To Protect Your Employees When Purchasing Health Insurance' - A fact sheet with tips employers can use when comparing benefits and costs of multiple insurance products. (U.S. Employee Benefits Security Administration)

[Guidance Overview] DOL Press Release Summarizes Proposed EBSA Regs Providing Enhanced Reporting Requirements and Enforcement Authority on Multiple Employer Welfare Arrangements (MEWAs)"The promoters, marketers and operators of MEWAs often have taken advantage of gaps in the law to avoid state insurance regulations, such as a requirement to maintain sufficient funding and adequate reserves to pay the health care claims of workers and their families. In the worst situations, operators of MEWAs have drained their assets through excessive administrative fees or outright embezzlement, resulting in harm to participants and their families. In some cases, individuals incur significant medical bills before they learn that claims are not being paid -- and that they are liable and need to pay their medical bills themselves. The Affordable Care Act includes provisions designed to remedy these gaps." (U.S. Employee Benefits Security Administration)

[Official Guidance] Text of Proposed EBSA Regs Providing Enhanced Reporting Requirements and Enforcement Authority on Multiple Employer Welfare Arrangements (MEWAs) (PDF)To be published in tomorrow's (Dec. 6) Federal Register; EBSA provided this copy of the rules as filed for publication. '[These proposed regulations implement] new enforcement authority provided to the Secretary of Labor by the Patient Protection and Affordable Care Act (Affordable Care Act) [which] authorizes the Secretary to issue a cease and desist order, ex parte (i.e. without prior notice or hearing), when it appears that the alleged conduct of a multiple employer welfare arrangement (MEWA) is fraudulent, creates an immediate danger to the public safety or welfare, or is causing or can be reasonably expected to cause significant, imminent, and irreparable public injury. The Secretary may also issue a summary seizure order when it appears that a MEWA is in a financially hazardous condition. The first proposed regulation establishes the procedures for the Secretary to issue ex parte cease and desist orders and summary seizure orders with respect to fraudulent or insolvent MEWAs. The second proposed regulation establishes the procedures for use by administrative law judges (ALJs) and the Secretary when a MEWA or other person challenges a temporary cease and desist order." (U.S. Employee Benefits Security Administration)

[Opinion] To Save on Health Care, First Crack Down on Fraud"[B]efore charging consumers more and eliminating valuable services, we should be much more aggressive in recovering money stolen from these taxpayer-supported programs. According to some estimates, health care fraud is a $250 billion-a-year industry, and about $100 billion of that is stolen from Medicare . . . and Medicaid . . . ." (The New York Times; free registration required)

'Mini-Med' Health Plan Waivers Top 700, Says HHS"As of Wednesday, HHS said it had approved a total of 733 waivers, up from 222 waivers that had been approved as of Dec. 3, 2010, the most recent prior date that information was available." (Business Insurance)

Fringe Benefits a 'Key Area' of Upcoming IRS AuditsExcerpt: "The IRS is on a mission to learn what issues are hiding in employers' records; thus, the [employment tax national research program] audits will prove to be more invasive than they would be if auditors had a specific target." (Thompson Publishing Group Inc.)

GAO Proactive Testing of ARRA Tax Credits for COBRA Premium Payments9 pages. Excerpt: "Employers claiming COBRA credits use quarterly or annual payroll tax returns to report the number of former employees on COBRA and the amount of premiums paid. These returns do not require employers to provide any supporting information about individuals enrolled in COBRA or premiums paid on their behalf, potentially allowing unscrupulous employers to lower their payroll taxes by fraudulently claiming COBRA credits." (U.S. Government Accountability Office)

[Guidance Overview] The Fraud and Abuse Provisions of the Health Care Reform ActExcerpt: "The recently enacted Affordable Care Act includes . . . fraud-and-abuse provisions affecting health care providers, including amendments to the False Claims Act (FCA), changes to the Anti-Kickback Statute (AKS), and new requirements related to the return of overpaymemts, as well as additional funding and new enforcement powers to fight fraud and abuse. Many of these changes are effective immediately. The developments that are most significant for health care providers are [covered in the target page]." (Proskauer Rose LLP)

Rescissions After The PPACA ? A PreviewExcerpt: "Under the PPACA, rescission is prohibited except in cases of fraud or misrepresentation. . . . The health insurance industry agreed to comply with this requirement ahead of the September effective date." (Roy Harmon via Health Plan Law)

[Guidance Overview] Health Care Reform Legislation Makes Significant Changes to Fraud and Abuse LawsExcerpt: "In keeping with the federal government's increased focus on health care fraud and abuse, the Act makes substantial changes to the Stark law. These changes have the potential to significantly affect providers' business and compliance strategies. Close attention should be paid to the issuance of HHS's regulations, as they will provide further guidance on implementation of the statutory provisions . . . ." (Pillsbury Winthrop Shaw Pittman LLP)

Making Your Healthcare Plan More Cost-Effective Through a Dependent Audit (PDF)Excerpt: "While a private-sector employer may see an audit as a way to help the bottom line, a public-sector employer could better serve the public interest through the audit -- since it is funded through tax dollars, it could save money on behalf of the public by verifying that claimed dependents are valid. Public-sector employers at the federal and state level have an additional reason to consider holding their own dependent audits -- the possibility of a watchdog government agency conducting an investigation." (Thompson Publishing Group)

Using Dependent Eligibility Audits to Keep Health Plans Healthy: A Case StudyExcerpt: "Because health plans are established for the benefit of eligible participants, any resources diverted to ineligible persons puts a strain on the plan's health, to the detriment of eligible participants. A recent project with a long-time client provides a good case study of the process and possible benefits of conducting a dependent eligibility audit." (Milliman)

[Guidance Overview] 2010 Medicare Premiums, Deductibles and CoinsuranceExcerpt: "Plan sponsors that pay the Medicare Part B premium or deductible should carefully review their plan documents and communications to assure that they are accurately stating the amount that the plan intends to pay. For example, plans that simply promise to pay the 'Part B deductible' may want to set that payment at a firm amount or maximum." (Segal Company)

Pfizer Settles Largest Health Care Fraud Case in HistoryExcerpt: "Pfizer Inc. was already under a corporate integrity agreement (CIA) stemming from an earlier Department of Justice (DOJ) settlement when it allegedly broke civil and criminal laws, triggering the largest health fraud settlement in American history. Now the pharmaceutical manufacturer will break another record, implementing what is believed to be the most extensive CIA ever imposed by the HHS Office of Inspector General (OIG)." (AISHealth.com)

$5-a-Day Cinergy Health Insurance Piles Up ComplaintsExcerpt: "TV ads touted Cinergy Health's low-cost medical insurance for as little as $5 a day -- the cost of a pack of cigarettes or a hamburger. But the policies promoted by the Aventura company delivered far less coverage than the ads promised, say New York state insurance regulators, who ordered Cinergy to take the ads off the air in mid-August. Florida may soon take action, as well. After an investigation, state insurance regulators also determined that the company that actually writes the policies, American Medical and Life Insurance, defrauded consumers with ads indicating that its limited-benefit health insurance plan offers comprehensive medical coverage. American Medical's license to sell insurance in Florida could be revoked." (The Miami Herald)

[Guidance Overview] Employee Who Signed Up Ineligible Individual for Health Plan Must Repay BenefitsExcerpt: "EBIA Comment: Numerous reported decisions have permitted ERISA plans and administrators to recover benefit overpayments made to plan participants and beneficiaries. And although the Knudson case took a narrow view of the remedies available under ERISA . . ., the Ninth Circuit made quick work of this case, citing ample support for restitution where fraud or wrongdoing is involved. " (Employee Benefits Institute of America)

Dependent Audits Surge As Employers Look for Cost-Cutting AlternativesExcerpt: "These days, employers will stop at nothing to eliminate excessive health plan costs. Increasingly, more benefit managers are finding they can wipe out millions of dollars worth in one fell swoop by conducting dependent eligibility audits. Employers conducting such audits generally realize 3% to 12% of covered dependents are not eligible for their plan, according to research by BMI audit services - thus, the increased interest." (Employee Benefit News; free registration required)

[Guidance Overview] 9th Circuit Affirms Reimbursement of Benefits for Fraudulent BeneficiaryExcerpt: "The 9th U.S. Circuit Court of Appeals has affirmed a lower court's decision that that a health plan administrator should be reimbursed for benefits it paid for a woman who was falsely represented as a participant's legal spouse. EBIA reports that the appellate court agreed with the U.S. District Court for the Western District of Washington that the $70,000 reimbursement is considered equitable relief under the Employee Retirement Income Security Act (ERISA). The courts rejected Ralph W. Cutter's argument that because the benefits were not paid directly to him and were not in his possession, the plan could not seek reimbursement from him." (PLANSPONSOR.com; free registration required)

Health Plans Ramp Up Efforts, Employ New Technologies, to Detect and Thwart FraudExcerpt: "Blues carriers are showing significant improvement in the use of technology to analyze claims. For example, . . . companies are better at putting prepay edits in place to watch out for claims that are impossible (e.g., pregnancy tests for a male) or improbable (e.g., services rendered on a national holiday). Moreover, . . . Blues plans have become savvier at finding aberrant bills through the use of post-pay analyses of claims." (AISHealth.com)

Blue Cross Accused of Deceptive PracticesExcerpt: "A federal [suit] accuses Blue Cross of a wide-ranging scheme to underpay claims from out-of-network hospitals. Methodist Hospital of Southern California claims Blue Cross refuses to let it transfer patients from emergency rooms, then underpays the hospital and sticks patients with hefty bills, falsely claiming the patients 'requested' to stay put. Methodist Hospital of Southern California accuses Blue Cross and Anthem affiliates in 10 states of RICO and ERISA violations. The insurance company faces similar actions in courts across the country. The scheme follows a well established pattern, according to the hospital, which quit the Blue Cross network in 2008, citing low payback rates that were 'onerous and one-sided in favor of Blue Cross.'" (Courthouse News Service)

California Regulators Shut Down Alleged Health Insurance SchemeExcerpt: "California regulators said they had shut down a labor union health insurance scheme that put hundreds of consumers at risk of losing coverage. The Department of Managed Health Care said Tuesday that it had obtained an order from an administrative judge barring Raymond and Jean Palombo of Riverside from selling health maintenance organization and preferred provider organization policies in California." (Los Angeles Times)

Health Insurers Refuse to Limit Rescission of CoverageExcerpt: "Executives of three of the nation's largest health insurers told federal lawmakers in Washington on Tuesday that they would continue canceling medical coverage for some sick policyholders, despite withering criticism from Republican and Democratic members of Congress who decried the practice as unfair and abusive. The hearing on the controversial action known as rescission, which has left thousands of Americans burdened with costly medical bills despite paying insurance premiums, began a day after President Obama outlined his proposals for revamping the nation's healthcare system." (Los Angeles Times)

Health Insurers Refuse to Limit Rescission of CoverageExcerpt: "Executives of three of the nation's largest health insurers told federal lawmakers in Washington on Tuesday that they would continue canceling medical coverage for some sick policyholders, despite withering criticism from Republican and Democratic members of Congress who decried the practice as unfair and abusive. The hearing on the controversial action known as rescission, which has left thousands of Americans burdened with costly medical bills despite paying insurance premiums, began a day after President Obama outlined his proposals for revamping the nation's healthcare system." (Los Angeles Times)

UAW OKs Healthcare Benefits Reduction for GM Retirees; DB Plan to ContinueExcerpt: "[I]nstead of GM contributing about $20 billion in cash and other contributions, the new VEBA will receive a note, payable in cash, with a principal amount of $2.5 billion. The note will make cash payments of $1.38 billion, including accrued interest, in 2013, 2015 and 2017. The VEBA also will receive preferred stock in the restructured company with a face value of $6.5 billion. The stock will pay an annual cash dividend of $585 million for as long as the VEBA holds the stock. Finally, the VEBA will receive 17.5% of the common stock issued by the restructured GM . . . ." (Business Insurance)

Employers See Substantial Savings from Dependent Eligibility AuditsExcerpt: "Mercer is seeing a dramatic rise in the number of inquiries and new business involving health plan dependent eligibility audits, with the number of Mercer-conducted audits more than doubling every year since 2006. According to a Mercer news release, the immediate and long-term savings gained from these audits can be substantial. Mercer conservatively estimates that 3% to 8% percent of covered family members (spouses and dependents) cannot produce valid verification of eligibility during an audit, and $1,900 is the average annual cost of providing health coverage for one dependent, based on data from Mercer's National Survey of Employer-Sponsored Health Plans." (PLANSPONSOR.com; free registration required)

Employers Use Eligibility Audits to Control Health Care CostsExcerpt: "With cost-savings in mind, some employers are conducting dependent eligibility audits to accurately determine who is covered under their plan. A recent survey conducted by the International Foundation of Employee Benefit Plans (IFEBP) found that 26% of U.S. employers conduct eligibility audits for their health care plans. 'Employers conduct an eligibility audit to ensure that every person covered by their health plan is an approved dependent,' said Julie Stich, Senior Information/Research Specialist with the IFEBP, in a press release. 'When the audit is conducted, employers often discover many people -- former spouses, adult children, non-immediate family members -- who are covered under the health plan even though they do not qualify as a dependent.'" (PLANSPONSOR.com; free registration required)

New Jersey Audit of Health Benefits Botched, Unions ChargeExcerpt: "Some three weeks after the state launched an audit of roughly 225,000 public employees throughout New Jersey to root out ineligible dependents receiving health benefits, the workers and their unions are seething over how the effort is being conducted. 'People were quite upset because this was handled so badly,' said Hetty Rosenstein, area director for the Communications Workers of America. Union leaders say there was little or no advance notice of the audit and the information it would seek. 'People get a letter and they're being asked for extremely invasive, very personal information,' Rosenstein said." (The Star-Ledger (Newark, New Jersey))

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